Prevention Of Embolism Research Articles

Substantial Improvement in Self-Reported Mental Health Following Total Hip Arthroplasty Occurs Independent of Anesthetic Technique

BackgroundThe influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA. MethodsProspectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups. ResultsPostoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement. ConclusionsPatient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.

Development and Validation of RP-HPLC Method for the Determination of Enoxaparin Sodium in Dry Injection Formulation.

Enoxaparin sodium is an anticoagulant medication that is used as a blood thinning agent. It is mostly used for the treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE). It is also used in certain surgeries and during pregnancy. For the treatment of acute coronary syndrome (ACS) and heart attacks, it may be used. Enoxaparin sodium was validated by the RP-HPLC method. A simple RP-HPLC method was developed in a single HPLC run in a dry powder injection formulation. All injections of HPLC sample were 20 μL volume. The chromatographic separation was completed in the isocratic mode. The used column was USP-L8 (250 mm × 4.6 mm) of BDS type of 10 μm meters in the same mobile phase throughout the analysis by using methanol and ultrapure water with a ratio of 7:93, respectively. The flow rate was 1.0 mL/min. The mobile phase was filtered through 0.45 μm filter paper, and isocratic elution was performed. The refractive index (RI) detector was used to analyze this sample. The specific peak of enoxaparin sodium was observed at 5:56 min. The calculated detection limit (LOD) was 0.351 ppm, and the calculated quantitation limit was 1.063 ppm. In repeatability of precision, the average calculated assay (%) was 100.85%, and the calculated RSD (%) was 0.01. In the accuracy test, the RSD (%) was 0.50, and the mean recovery (%) was 100.35. The system's suitability was within the limit. This newly developed method is proposed according to ICH guidelines, and rules and can be applied effectively for the exact estimation of enoxaparin sodium in injection formulation. This newly developed methodology is affordable in cost as long as less time is taken and the consumption of samples is in smaller quantities for every investigation. In medicinal chemistry, the USP (United States Pharmacopeia) and BP (British Pharmacopeia) are directly involved in production as well as in quality testing.

Role of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis

Abstract Background/Introduction Embolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan. Purpose The present study aimed to describe the role of thoracoabdominal imaging (TA-Im) on diagnosis and management of patients with suspected IE. Methods This study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. Results Among 966 episodes with IE suspicion and TA-Im, 740 (77%) contrast-enhanced CT, 158 (16%) 18F-FDG PET/CT and 68 (7%) non-contrast-enhanced CT. The majority of patients (528; 55%) were without thoracoabdominal symptoms. At least one EE was found in 205 (21%) episodes. Based on TA-Im findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively [2 (0.5%) and 5 (1%) in asymptomatic episodes, respectively]. Table shows the type of embolic events and their impact on diagnosis in episodes with suspected IE. Among the 413 patients with possible or definite IE, at least one EE was found on TA-Im in 143 (35%) episodes. Together with the presence of left-side valvular vegetation &amp;gt;10mm, the results of TA-Im established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. Among the subgroup of episodes (n=127) with left-side vegetation &amp;gt;10mm, TA-Im established a surgical indication in 12% of episodes (15 patients), 10% among asymptomatic episodes (7 out of 73). Figure shows the changes in diagnostic classification and management due to TA-Im results in patients suspected (A) and those with IE (B). Conclusion TA-Im performed in asymptomatic patients with IE suspicion improved the diagnosis of IE in only a small proportion of patients; this proportion was similarly low in symptomatic patients. The role of systematic TA-Im in the clinical management of asymptomatic IE patients remains unclear, since it identified a new indication for valvular surgery in only a small proportion of patients. The scenario, where the benefit of TA-Im on management is a patient with a vegetation &amp;gt;10mm; in those patients, systematic TA-Im may lead to a new surgical indication in 10% of cases.Embolic eventsDiagnosis and mangement

Abstract 16694: Impact of Frailty in Non-Valvular Atrial Fibrillation Elderly Patients on Anticoagulation Therapy

Background: As the number of elderly people increases, we see more chances to consider anticoagulant therapy for elderly people with frailty. Research Question: Does frailty affect the outcome of anticoagulation therapy? Goals: To show the impact of frailty to the effectiveness and safety of anticoagulant therapy with rivaroxaban in elderly Japanese non-valvular atrial fibrillation (NVAF) patients. Methods: The GENERAL (GENeral practitioners and Embolism pRevention in NVAF patients treated with RivAroxaban: real-Life evidence) study was an observational study of elderly NVAF patients with rivaroxaban at general practice settings in Japan. We employed multiple imputation for missing baseline characteristics, and propensity score (PS) matching to estimate the treatment effect of frailty accounting for the patients’ imbalance. In each imputed and PS matched data set, the treatment effects of frailty were assessed with Cox proportional hazard models for each outcome. Results: A total of 5,717 (mean 79.3 years old, male 64.8%) were observed for a mean of 2.0 years and up to 3 years. Of these, 485 (8.5%) were classified frailty. Variable missing rates ranged from 0% to 35%. After the imputation and matching, the patients' backgrounds were well matched and balanced between two groups. Frailty was not associated with the primary endpoint: stroke/systemic embolism (Hazard Ratio [HR] 1.128, 95% Confidence Interval [CI]: 0.500 - 2.547, p=0.767). Also, frailty was not associated with all-secondary endpoints (Figure 1). In the sensitivity analyses with the complete cases, the cases with any missing variables were deleted, frailty was significantly related with outcome events except for the bleeding events (Figure 2). Conclusion: In our study results, frailty did not affect the effectiveness or safety of anticoagulant therapy with rivaroxaban for this population. However, we should consider the necessity and benefit for this population to start anticoagulant therapy.

Apixaban Vs Vitamin K Antagonist As Anticoagulant Therapy in Patients with End-Stage Kidney Disease on Hemodialysis and with Atrial Fibrillation

BACKGROUND Evidence of net safety and benefit of anticoagulation for stroke prevention in patients with end-stage kidney disease (ESKD) on hemodialysis and with atrial fibrillation (AF) is lacking because patients with advanced CKD and those with end-stage kidney disease (ESKD) have been excluded from randomized clinical trials of stroke prevention in AF. In Europe, apixaban is not approved for the indication of prevention of stroke and systemic embolism in adult patients with ESKD on hemodialysis and AF. AIM To assess the effectiveness and safety according to Apixaban or VKA treatment. The effectiveness outcome was defined by ischemic stroke, all-cause death and myocardial infarction. The safety outcome was defined by a first event of major bleeding, clinically relevant nonmajor bleeding, or all-cause death. METHODS Unicenter, observational and retrospective study. Data was collected between January 2018 and July 2022. We included adult patients with ESKD on hemodialysis and AF and a CHA2DS2-VASc score ≥2 treated with low dose of Apixaban (2.5 mg twice daily) or VKA from the beginning of treatment. Patients in the VKA group received Acenocoumarol. Demographic, laboratory data and clinical presentation of AF were collected. Patients had a minimum follow-up (FU) of 6 months. Apixaban plasma drug concentrations were measured during the FU (week 1 and month 3). Blood samples were draw just before the next dose (Ctrough) and at 2-3 hours (Cpeak) after of drug intake using the Technoclone anti-Xa assay from Technoclone (Vienna-Austria). Bleeding events were classified according to ISTH criteria. RESULTS A total of 302 patients with NVAF and ESKD on hemodialysis were included. Among all patients, 192 (63.5%) were treated with Apixaban and 110 VKA. Mean FU was 14.8 and 12.5 months (DOAC vs VKA; p:0.53). Demographic characteristics are summarised in table 1. In Apixaban group, 100% of patients received reduce-dose, according to the care protocol established in our center and showed predictable pharmacokinetic, Ctrough (94.5- 180 μg/L) and Cmax (150-419 μg/L). In VKA group, Time in therapeutic range (international normalized ratio, 2.0-3.0) for Acenocumarol treated patients was 42% (interquartile range, 19%-60%). Stroke or systemic embolism occurred in three patients in the Apixaban group (1.04 %/year) and seven patients in the VKA group (7.2 %/year) [DOAC vs LMWH; p&amp;lt;0.05]. The apixaban group experienced fewer overall bleeding events than the VKA group (17.3% vs 39.7%; P = .01); this significant difference persisted in adjusted analysis (OR = 0.13; 95% CI = 0.04-0.42; P = .001). Major bleeding events were less frequent in the apixaban group compared with patients on VKA (4.7% vs 25%; P = .01). There were no significant differences regarding in all-cause mortality, 18.8% versus 21.5% respectively. CONCLUSIONS Compared to VKA, our findings suggest that low dose of apixaban is a safe and effective alternative in patients with AF and ESKD on hemodialysisis and low dose of apixaban showed predictable pharmacokinetic.

POSSIBILITIES OF CORRECTING CELLULAR-HUMORAL IMMUNE DISORDERS AND CYTOKINE STATUS IN HIGH-RISK PREGNANT WOMEN FOR THE DEVELOPMENT OF PREECLAMPSIA

POSSIBILITIES OF CORRECTING CELLULAR-HUMORAL IMMUNE DISORDERS AND CYTOKINE STATUS IN HIGH-RISK PREGNANT WOMEN FOR THE DEVELOPMENT OF PREECLAMPSIA

Non-Vitamin K Antagonist Oral Anticoagulants in Differentiated Approach to the Use in Cardiological Practice: Literature Review

Non-vitamin K antagonist oral anticoagulants (novel oral anticoagulants, NOACs) are important pharmaceuticals for prevention of stroke and systemic embolism in non-valvular atrial fibrillation patients. Vitamin K antagonist warfarin usage is limited due to its pharmacokinetic and pharmacodynamic parameters. In modern conditions, NOACs are widely used. This literature review includes the most interesting clinical studies where anticoagulants were used. Main pharmacological properties of non-vitamin K antagonist oral anticoagulants have been investigated in these clinical studies.&#x0D; The aim. To answer the question about which anticoagulant is preferable for use in particular clinical situation.&#x0D; Results. In order to prevent venous thrombosis, conservative and surgical treatment is used. It is the use of anticoagulants during conservative therapy that allows to extend the life expectancy of patients at high risk of thrombosis. Unlike warfarin, the use of NOACs helps to avoid high risk of bleeding. Drugs of this group have short half-life, standard dosage, and predicted pharmacological effect.&#x0D; Conclusions. New data about comparative efficacy and safety of treatment with NOACs (dabigatran, rivaroxaban, edoxaban, apixaban) in order to prevent thromboembolism in patients with atrial fibrillation are presented. The peculiarities of anticoagulant therapy in elderly patients, patients with coronary artery disease, atrial fibrillation, chronic kidney disease, patients in pre- and postoperative periods are discussed. Prolonged study of drugs of this group will enable doctors to use them without endangering the patients’ lives. NOACs, despite obtained data about their effectiveness and safety, in our opinion, deserve attention and require further study.

Surgical Challenges in Infective Endocarditis: State of the Art.

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Impact of leaflet thrombosis on valve haemodynamic status after transcatheter aortic valve replacement

ObjectivesThe effect of subclinical leaflet thrombosis, characterised by hypoattenuated leaflet thickening (HALT), on the valve haemodynamic function and durability of the bioprosthetic valve, is not yet determined. We determined the...

Antithrombotic Medication and Major Complications After Mechanical Aortic Valve Replacement

Patients with mechanical aortic valve replacement (AVR) require lifelong vitamin K antagonist (VKA) therapy for stroke and systemic embolism prevention. However, VKA treatment predisposes patients to various types of bleeding. In the present study, we sought to assess the success of antithrombotic therapy and the occurrence and timing of strokes and bleeding events after mechanical AVR. A total of 308 patients who underwent isolated mechanical AVR were included in the study, and follow-up data were completed for 306 patients (99.4%). The median follow-up time was 7.3 (interquartile range 4.2 to 10.9) years. The risk for major bleeding was 5-fold compared with major stroke (6.2% vs 1.3% and 20.9% vs 4.0%, respectively; events rates 3.1 vs 0.5 per 100 patient-years, respectively) at 30-day and long-term follow-up, indicating good efficacy but inadequate safety of stroke prevention. At the time of the early postoperative major bleeding, the international normalized ratio was under the therapeutic range in 73.7% of the patients. However, most patients were on triple antithrombotic treatment consisting of subcutaneous enoxaparin, VKA, and a tail effect of discontinued aspirin. During the long-term follow-up, the most common site of bleeding was gastrointestinal (41.7%), followed by genitourinary bleeding (23.3%) and intracranial hemorrhage (18.3%). Furthermore, mortality was relatively high, with a 10-year survival estimate of 78.3%. In conclusion, although ischemic stroke is a well-identified adverse event after mechanical AVR, it seems that major bleeding is a frequent clinically relevant complication during perioperative and long-term follow-up. This finding underscores the recognition and management of modifiable bleeding risk factors.

The place of dabigatran in the treatment of patients with atrial fibrillation in the light of modern recommendations

This review is devoted to the aspects of anticoagulant therapy in patients with atrial fibrillation in the light of the modern understanding of this type of arrhythmia as a polymorbid continuously developing syndrome. According to experts, the management strategy of this category of patients is based on an integrated assessment, including the risk of stroke, the presence of symptoms, assessment of structural heart disease and mandatory accounting of concomitant pathology. In this approach, the appointment of anticoagulant therapy as a prevention of stroke in a patient with atrial fibrillation is put in the first place. At the same time, experts emphasize the need for a dynamic reassessment of risks, as well as the use of a multidisciplinary team of specialists to make a complex decision. The review summarizes the basic concepts of the integrated approach, describes various variants of clinical scenarios, including aspects of anticoagulant maintenance of cardioversion and catheter ablation, multicomponent therapy after percutaneous coronary intervention. A separate chapter is devoted to modern algorithms of perioperative management of a patient receiving oral anticoagulants, which is based on the stratification of interventions according to the risk of perioperative bleeding and the characteristics of the anticoagulant prescribed to the patient. The place of dabigatran in the primary and secondary prevention of stroke and systemic embolism in patients with atrial fibrillation is described, studies that served as the basis of the evidence base for the use of dabigatran in patients with atrial fibrillation are presented. The data of register observations, meta-analyses devoted to the evaluation of the efficacy and safety of dabigatran in certain categories of patients (elderly patients, patients with chronic heart failure, diabetes mellitus) are presented, which form the basis of decision-making in real clinical practice.

A DIFFERENTIATED APPROACH IN THE TREATMENT OF ACUTE FLOATING VENOUS THROMBOSIS OF THE INFERIOR VENA CAVA SYSTEM

We analyzed the results of surgical treatment floating DVT. Unfortunately, there are no randomized studies in the world regarding the determination of clear tactical approaches to the treatment of floating venous thrombosis, in many cases doctors make decisions about the choice of surgical tactics based on their own experience. In our research, we tried to systematize our own experience and form the basic principles of determining surgical tactics in the treatment of floating venous thrombosis. To date, anticoagulants, surgical interventions in the form of thrombectomy, and thrombolytic therapy are used in the treatment of DVT. Unfortunately, at the moment, no consensuses clearly define the issues of surgical treatment of floating venous thrombosis, venous thrombosis in pregnant women, venous thrombosis complicated by pulmonary embolism, venous thromboembolism.&#x0D; The goal. The aim of the research was to develop a surgical tactics in the treatment of floating DVT of the inferior vena cava.&#x0D; Materials and methods. The treatment of 76 patients with floating DVT from 2008 to 2020 were analyzed.&#x0D; In a research among patients with floating DVT in 15(20%) patients experienced thrombosis of the inferior vena cava, 19(25%) patients had ilio-femoral thrombosis in 17(22%) patients with femoral - popliteal thrombosis in 9(12%) patients with popliteal - tibial.&#x0D; Deep vein thrombosis complicated by pulmonary embolism with medium and high risk of death was observed in 10 (13%) patients. Among them, floating thrombosis of the iliac-femoral segment was observed in 4 patients.&#x0D; Floating thrombosis of deep veins in pregnant women was observed in 6 (8%) patients.&#x0D; Among patients, 20 (296%) patients were admitted within 1 day of the onset of the disease, 30 (39%) patients on 2-3 days, 11 (14%) patients on 4-7 days, 8 on 8-14 days (11%) patients, from the 15th day - 7 (10%) patients).&#x0D; The results. Patients with long of floating part of the more than 4 cm, we used an active surgical tactics. In the presence of the floating thrombus a total iliac vein thrombectomy we performed in 12 patients with the removal of the floating thrombus with femoral access. For the prevention of pulmonary embolism in these cases we implanted a temporary cava-filter. When flotation thrombus in the external iliac vein, we used the technique of thrombectomy using Fogarty two catheters in 12 patients. When flotation clots in common femoral vein and distally using a vein thrombectomy with clamping head above floating thrombus. When treating patients with floating DVT, pulmonary embolism complicated with medium and high risk of death, we used systemic thrombolysis with pre- implantation temporary coffee filter in patients with floating DVT, pulmonary embolism complicated with medium and high risk of death, we used systemic thrombolysis with pre- implantation temporary coffee filter. In the presence of pregnancy and floating thrombosis thrombectomy was performed with the removal of the thrombus floating. In our research, when performing the surgical treatment of DVT no cases of pulmonary embolism during or after treatment were observed. In 100 % of patients after treatment has been a clinical improvement in all cases floating DVT was eliminated floating nature of the danger of thrombosis and pulmonary embolism.&#x0D; Conclusions. In the presence of a floating DVT of the inferior vena cava system with a length of the floating part of the thrombus greater than 4 cm, it is necessary to use an active strategy of thrombus removal. When performing thrombectomy, it is necessary to use methods of surgical prevention of PE, taking into account the localization of the floating part.

Evaluating efficacy and safety of oral anticoagulation in adult patients with atrial fibrillation and cancer: A systemic review and meta-analysis

BackgroundAtrial fibrillation (AF) is common among patients with cancer. Patients with cancer and AF require anticoagulant therapy [direct oral anticoagulants (DOAC) or vitamin K antagonist (VKA)] for stroke and systemic embolism (SE) prevention. We sought to assess the rates of stroke/SE and major bleeding in patients with cancer and AF on oral anticoagulant therapy (DOAC or VKA). MethodsA systematic search of MEDLINE and EMBASE was conducted. The primary efficacy and safety outcome were stroke/SE and major bleeding (as per the International Society on Thrombosis and Haemostasis definition), respectively. Incidence rates (IR) were pooled using random effects model (event per 100 patient-years). Incidence rate ratios (IRR) were computed using a Poisson regression model with associated 95% confidence intervals (CI) using R software (version 4.0.3). ResultsOf the total 2,153 article records that were screened, 22 observational studies from 12 different countries were included in the meta-analysis (n = 94,980 patients). The IR of stroke/SE was 1.81 (95% CI: 0.89 to 3.68) and 3.41 (95% CI: 1.38 to 8.41) per 100 patient-years for patients receiving a DOAC and VKA, respectively (IRR: 0.63 (95%CI: 0.47–0.84)). The IR of major bleeding was 2.59 (95%CI: 1.54 to 4.38) and 3.60 (95% CI: 1.68 to 7.71) per 100 patient-years for patients receiving a DOAC and VKA, respectively (IRR: 0.76 (95% CI: 0.55 to 1.04)). ConclusionDOACs compared to VKA seem to provide a significant reduction in the risk of stroke/SE and a good risk-benefit ratio profile for safety outcomes in this patient population.

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism—the Find-AF 2 study—rationale and design

Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism. Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur. The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.

Impact of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis

BackgroundEmbolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan. The present study aimed to describe the role of thoracoabdominal imaging, either thoracoabdominal-pelvic Computed Tomography or 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography, on diagnosis and management of patients with suspected IE. MethodsThis study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. ResultsAmong 966 episodes with suspected IE and thoracoabdominal imaging, 528 (55%) patients were asymptomatic. At least one EE was found in 205 (21%) episodes. Based on thoracoabdominal imaging findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively. Among the 413 patients with IE, at least one EE was found on thoracoabdominal imaging in 143 (35%) episodes. Together with the presence of left-side valvular vegetation >10 mm, the results of thoracoabdominal imaging established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. ConclusionsThoracoabdominal imaging performed in asymptomatic patients with suspected IE improved the diagnosis in only a small proportion of patients. Thoracoabdominal imaging led to a new surgical indication (in association with left-side valvular vegetation >10 mm) in only a small percentage of patients.

Optimal anticoagulation intensity with warfarin for the prevention of thromboembolism with minimal bleeding in Asian patients with atrial fibrillation: multi-center, randomized controlled trial

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Korean Society of Cardiology Background Anticoagulation with warfarin in Korean patients with atrial fibrillation (AF) often has been decreased as an international normalized ratio (INR) of prothrombin time between 1.6 to 2.6 for the fear of bleeding, although universal criteria recommends to adjust it between 2.0 to 3.0. Methods In this randomized, open-label trial, we compared low intensity anticoagulation (INR 1.6 to 2.6) with standard intensity anticoagulation (INR 2.0 to 3.0) with warfarin in 616 patients with AF and at least 1 risk factor for stroke. The per-protocol, intension-to-treatment analysis was designed to determine whether low-intensity anticoagulation (n=308) was non-inferior to standard-intensity anticoagulation (n=308) with warfarin for the primary end point of net clinical outcomes defined as the sum of stroke, systemic embolism, major bleeding and death. Results The median follow-up duration was 1.8 years. Baseline characteristics of the two groups were comparable. Median value of INR was significantly higher in standard-intensity group than low-intensity group (2.19 vs. 2.07, p=0.002), whereas that of time in the therapeutic range was comparable between the 2 groups. The rate of primary outcome was 1.55% per year in low-intensity anticoagulation, as compared with 2.46% per year in standard-intensity anticoagulation (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.22 to 1.74, p for non-inferiority &amp;lt;0.001, p for superiority = 0.365). New-onset stroke occurred in 2 patients (0.52% per year) in low-intensity group and in 5 patients (1.23% per year) in standard-intensity group (HR 0.42, 95% CI 0.08 to 2.17, p for non-inferiority &amp;lt;0.001, p for superiority = 0.297). Major bleeding occurred in 4 patients (0.88% per year) in low-intensity group and 5 patients (1.23% per year) in standard-intensity group (HR 0.84, 95% CI 0.22 to 3.17, p for non-inferiority &amp;lt;0.001, p for superiority = 0.796). Major and minor bleeding occurred in 37 patients (9.58% per year) in low-intensity group and in 40 patients (9.85% per year) in standard-intensity group (HR 0.97, 95% CI 0.59 to 1.58, p for non-inferiority &amp;lt;0.001, p for superiority = 0.899). Conclusion In Korean patients with AF, low-intensity anticoagulation with warfarin as INR 1.6 to 2.6 was non-inferior to standard-intensity anticoagulation with warfarin as INR 2.0 to 3.0 for the prevention of net-clinical outcome, and stroke or systemic embolism. There was no significant difference for the risk reduction of major bleeding.

Reduced Left Atrial Rotational Flow Is Independently Associated With Embolic Brain Infarcts

BackgroundUp to 25% of embolic strokes occur in individuals without atrial fibrillation (AF) or other identifiable mechanisms. ObjectivesThis study aims to assess whether left atrial (LA) blood flow characteristics are associated with embolic brain infarcts, independently of AF. MethodsThe authors recruited 134 patients: 44 with a history of ischemic stroke and 90 with no history of stroke but CHA2DS2VASc score ≥1. Cardiac magnetic resonance (CMR) evaluated cardiac function and LA 4-dimensional flow parameters, including velocity and vorticity (a measure of rotational flow), and brain magnetic resonance imaging (MRI) was performed to detect large noncortical or cortical infarcts (LNCCIs) (likely embolic), or nonembolic lacunar infarcts. ResultsPatients (41% female; age 70 ± 9 years) had moderate stroke risk (median CHA2DS2VASc = 3, Q1-Q3: 2-4). Sixty-eight (51%) had diagnosed AF, of whom 58 (43%) were in AF during CMR. Thirty-nine (29%) had ≥1 LNCCI, 20 (15%) had ≥1 lacunar infarct without LNCCI, and 75 (56%) had no infarct. Lower LA vorticity was significantly associated with prevalent LNCCIs after adjustment for AF during CMR, history of AF, CHA2DS2VASc score, LA emptying fraction, LA indexed maximum volume, left ventricular ejection fraction, and indexed left ventricular mass (OR: 2.06 [95% CI: 1.08-3.92 per SD]; P = 0.027). By contrast, LA flow peak velocity was not significantly associated with LNCCIs (P = 0.21). No LA parameter was associated with lacunar infarcts (all P > 0.05). ConclusionsReduced LA flow vorticity is significantly and independently associated with embolic brain infarcts. Imaging LA flow characteristics may aid identification of individuals who would benefit from anticoagulation for embolic stroke prevention, regardless of heart rhythm.

Percutaneous Cardiac Chambers and Pulmonary Artery Aspiration.

The clinical guidelines and current practice in the field of removable cardiovascular pathologies are not aligned and are in fluctuation. The purpose of this review manuscript is to propose adjustments and forecast changes in clinical practice in this field ahead of irrefutable evidence. Percutaneous aspiration devices may be used in case of pulmonary embolism, endocarditis, cardiac thrombi, and tumors. The rationale of treatment includes prevention of emboli, endocarditis debulking and modification, sampling of tissue, and salvage therapy. We are describing the contemporary treatments that are occurring in practice outside and above guidelines. The current standard therapy for the above-mentioned entities is not supported by robust data. Moreover, evidence suggesting priority for the use of percutaneous aspiration devices as first-line therapy-before turning to or in lieu of surgery or thrombolysis-continues to accumulate. However, guidelines still mention percutaneous aspiration only as an alternative to standard treatment. In the current review, we discuss the pathophysiology that supports percutaneous cardiac and pulmonary artery aspiration, the commonly used devices for that purpose, their clinical evidence, and accordingly propose a modified approach to patient management. In addition, this review highlights fluid dynamic principles important in matter extraction in order to better define the utility of catheter-based technologies in different cardiovascular territories. The target diseases encompassed in this review are pulmonary embolism, cardiac masses, and vegetations.

Prevalence and risk factors for pulmonary embolism in children with sickle cell disease: an institutional retrospective cohort study.

The study was conducted to examine prevalence of pulmonary embolism in children with sickle cell disease (SCD) and identify potential risk factors associated with pulmonary embolism in a single tertiary paediatric centre. Children with SCD between 0 and 21 years of age from January 2010 to January 2021 were included. Pulmonary embolism was initially identified using International Classification of Diseases (ICD)-9 or 10 codes and confirmed with manual chart review of identified cases. Logistic regression analysis was performed to assess association between SCD specific and general thrombotic risk factors and pulmonary embolism. We identified 492 unique patients with SCD with a median age of 11 years (interquartile range: 4-18). A total of eight (1.6%) patients developed a pulmonary embolism. Patients with pulmonary embolism were significantly older (median, interquartile range: 20.5, 14-21 years) than patients without pulmonary embolism (median, interquartile range: 10, 4-17 years). Central nervous system (CNS) vasculopathy and erythrocytapheresis were significantly associated with pulmonary embolism on univariable logistic regression analysis. A previous diagnosis of deep vein thrombosis (DVT) was significantly more common among patients with pulmonary embolism than among those without pulmonary embolism (50 vs. 5.2%; P < 0.0001). Prevalence of pulmonary embolism in children with SCD was high. Risk factors associated with pulmonary embolism in this study such as CNS vasculopathy or erythrocytapheresis could suggest that the risk for pulmonary embolism in SCD may be related to the severity of disease state. Future studies are needed on pulmonary embolism prevention strategies.

Transcatheter closure of patent foramen ovale using the Cocoon occluder: A multicenter retrospective study

BackgroundThe Cocoon patent foramen ovale (PFO) occluder is a new device especially designed for transcatheter closure of PFO. This occluder has some distinctive structural modifications aimed at reducing the risk of major complications of transcatheter PFO closure. In this report we present our initial experience to evaluate the efficacy and safety of the Cocoon PFO occluder in 253 patients who underwent transcatheter PFO closure. MethodsThe study cohort included 253 patients (median age 45 years) with embolic stroke of undetermined source who underwent attempted transcatheter closure of PFO for secondary prevention of paradoxical embolism. Patients were enrolled retrospectively from five sites in Greece and one in Romania between December 2016 and January 2021, and the median follow-up period was 28 months (range 12–48 months). Clinical and laboratory data from each participating center were sent to an electronic registry for evaluation and statistical analysis. ResultsThe Cocoon PFO occluder was permanently implanted in all patients. At 6 months, complete occlusion of PFO was observed in 251/253 (99.2%) patients. Three (1.2%) patients had a trivial residual shunt. Thrombus formation on the device, which was successfully treated with recombinant tissue plasminogen activator infusion, was observed in one (0.4%) patient. No other complications occurred. During a median follow-up period of 28 months, 3 (1.2%) patients, aged 64–67 years, developed new onset paroxysmal atrial fibrillation. No neurologic events, cardiac erosions, allergic reactions to nickel, or thrombus formation occurred. ConclusionThe Cocoon PFO occluder is an effective and safe device that adds to our armamentarium for transcatheter closure of PFO.